Early Experience and outcomes with Robotic retroperitoneal lymph node dissection
Da David Jiang, MS MD, MJ Counsilman, MD, Joseph Black, MD, Allison Kleeman, BS, Adrian Waisman, MD, Catrina Crociani, MS, Peter Chang, MPH MD, Boris Gershman, MD, Andrew A. Wagner, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.
BACKGROUND: Retroperitoneal lymph node dissection (RPLND) remains a standard of care option in the management of early stage testicular cancer and in the setting of for post-chemotherapy NSGCT with residual retroperitoneal mass. As robotic expertise with complex surgery improves, more teams have embraced this approach which offers the promise of lower morbidity than a standard, open approach via midline incision. We present our single institution experience with robotic RPLND for testis cancer as well as a video illustration of our technique. METHODS: All robotic RPLND were performed by either two-fellowship trained urology attendings or an attending and fellow. Patients were positioned in a modified lateral position and either the Si or the Xi Da Vinci robot was used. Bilateral template dissection was performed for all post-chemotherapy RPLND (PC-RPLND) cases and required re-positioning and re-docking, a process made easier with the Xi robot. For one bilateral template post-chemotherapy case we used the 'reverse prostate' position with the robot docking over the patient’s head and patient supine and in Trendelenberg. For stage I disease, the decision for bilateral or unilateral template dissection was individualized for each patient.
RESULTS: A total of 14 patients underwent robotic RPLND from 2016 to 2020. Patient demographics and perioperative outcomes are highlighted in the Table. Of note, 64% of patients underwent primary RPLND while 36% were in the post-chemotherapy setting. Median operative time for unilateral cases was 4.4 hrs (IQR 4.4-4.6) and for bilateral cases was 6.2 hrs (4.8-7.8). Estimated blood loss (EBL) was 100mL (IQR 63-213) and the median hospital stay was 2 days (IQR 1-2). Overall, 4 patients experienced complications within 90 days and the highest was Clavien Dindo 2--abdominal pain with emergency room visit which was assumed due to pancreatitis from passing a gallstone. One late complication occurred beyond 90 days post-op: a patient presented with a unilateral ureteral stricture, which was successfully managed endoscopically with dilation. None of the patients in the primary RPLND setting had positive nodes however 4 patients in the PC-RPLND setting had positive nodes (3 with teratoma and 1 with residual germ cell tumor who received further chemotherapy). All patients are without recurrence at a median follow-up of 24 (IQR 6.3-42) months. Of those that we were able obtain information on antegrade ejaculation (n = 9), six patients (67%) retained ejaculation. Of the three patients without antegrade ejaculation, all were in patients undergoing PC-RPLND. CONCLUSIONS:Robotic RPLND is safe and feasible in both primary and post-chemotherapy settings in properly selected patients, with shortened convalence compared to the open approach. Early experience suggests a low rate of perioperative complications and excellent oncologic outcomes. 
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